Provider Demographics
NPI:1003425281
Name:SHATTUCK, JESSICA (APRN-CNM, WHNP-BC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SHATTUCK
Suffix:
Gender:F
Credentials:APRN-CNM, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 SLIPPERY ROCK LN
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-3155
Mailing Address - Country:US
Mailing Address - Phone:440-610-3710
Mailing Address - Fax:
Practice Address - Street 1:108 SLIPPERY ROCK LN
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:OH
Practice Address - Zip Code:44017-3155
Practice Address - Country:US
Practice Address - Phone:440-610-3710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0027135363LW0102X
OH0019465367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health